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HospitalistWeekly 9-24-08

Highlights

• ICU patients experience higher rate of PTSD
• Study supports safety and efficacy of extended tPA treatment window

Disease prevention

• Health officials try to raise awareness of DVT

Drug news

• FDA bans dozens of generics from entering U.S. over quality concerns

From ACP Internist

• On the blog: new diabetes device on the horizon

Cartoon caption contest

• Vote for your favorite entry

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Highlights

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ICU patients experience higher rate of PTSD

About one in five, or 20%, of intensive care unit (ICU) patients experiences post-traumatic stress disorder (PTSD) symptoms following discharge, according to a literature review published in the September/October issue of the Journal of General Hospital Psychiatry. Experiencing or witnessing life-threatening events, such as serious accidents, violent personal assaults or natural disasters are typical precursors to PTSD.

The review, which comes out of the Department of Psychiatry and Behavioral Sciences at the University of Washington, School of Medicine in Seattle, analyzed 15 previously published studies that comprised data from 1,745 former ICU patients. Researchers reported that being treated in an ICU can set off PTSD symptoms such as nightmares, flashbacks, irritability, anger and emotional detachment, and have negative effects on the patients and their quality of life.

Patients with a history of anxiety or depression were more likely to develop PTSD after an ICU stay, as were ICU patients who were sedated with benzodiazepine medications and those who recalled alarming ICU treatment experiences after discharge.

Studies based on clinician diagnosis found that 19% of former ICU patients developed PTSD symptoms, whereas studies that relied on patient symptom questionnaires found that 22% of ICU survivors developed PTSD symptoms. PTSD symptoms often extend for months or years after the traumatic event and typically affect about 6.8% of the general U.S. population.

Given that about 4 million people per year spend time as ICU patients in the U.S. alone, the prevalence of ICU-associated PTSD represents a significant public health issue, according to the study’s lead author. Health care providers can use the results of this review to prepare families of ICU patients for the possibility that their relatives could have problems with anxiety and PTSD symptoms after an ICU stay.

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Study supports safety and efficacy of extended tPA treatment window

Thrombolysis with alteplase may be safe and effective up to four-and-a-half hours after onset of acute ischemic stroke despite the currently approved three-hour treatment window, according to an international observational study published online by The Lancet.

The potential for increased risk of hemorrhage has been the rationale for limiting use of tissue plasminogen activator (tPA) to within three hours of stroke onset. However, when researchers compared 11,865 patients treated within three hours of stroke with 644 patients who were treated within three-to-four-and-a-half hours of stroke, they found that the risk of hemorrhage complications and death was not significantly higher for the second group. The retrospective analysis was based on patient data recorded in Safe Implementation of Treatments in Stroke (SITS), a prospective Internet-based audit of the International Stroke Thrombolysis Registry (ISTR).

The mortality and hemorrhage rates for those receiving tPA within the standard treatment timeframe were 12.2% and 1.6%, respectively, compared with 12.7% and 2.2%, respectively, in the three-to-four-and-a-half hour group. Patients in both treatment groups also exhibited similar outcomes as far as their ability to perform everyday activities three months after stroke; 56.3% for those in the standard treatment group and 58.0% in the extended timeframe group. However, researchers did find a non-significant increased risk of symptomatic intracranial hemorrhage and mortality at three months in patients after three hours.

The trial supports efforts to extend the timeframe for thrombolysis, said an accompanying editorial. However, the goal is to eventually move away from the rigid timeframes associated with tPA to treatment based on imaging that can assess brain pathophysiology and tissue viability.

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Disease prevention

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Health officials try to raise awareness of DVT

Deep vein thrombosis (DVT) is the target of new awareness campaigns announced last week by the AHRQ and the Surgeon General's office.

Acting Surgeon General Steven K. Galson, MD, issued a call to action urging clinicians and patients to reduce the incidence of deep vein thrombosis and pulmonary embolism (PE). Annually, the conditions affect an estimated 350,000 to 600,000 Americans and contribute to at least 100,000 deaths, a press release said. Risk factors, in addition to hereditary clotting disorders, include being hospitalized or confined to bed rest, having major surgery, suffering a trauma, or traveling for several hours, Dr. Galson noted.

The call to action resulted from a 2006 Surgeon General's Workshop on the disorders and its goals include:

• increasing awareness about DVT and PE;
• encouraging evidence-based practices for DVT; and
• obtaining more research on the causes, prevention and treatment of DVT.

The AHRQ has released two new resources to help physicians and consumers prevent the blood clots from developing. The clinician guide, "Preventing Hospital-Acquired Venous Thromboembolism: A Guide for Effective Quality Improvement," is a 60-page guide which details how to start, implement, evaluate and sustain a quality improvement strategy. It includes case studies, as well as example forms.

The AHRQ's consumer booklet is a 12-page easy-to-read resource that helps patients and their families identify the causes and symptoms of blood clots, learn tips on how to prevent them and know what to expect during treatment. Both guides and a press release are on the AHRQ Web site.

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Drug news

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FDA bans dozens of generics from entering U.S. over quality concerns

The FDA banned more than 30 Indian-made generic drugs from entering the U.S. last week over "deficiencies… in the manufacturing process," a press release said.

The drugs, made by Ranbaxy Laboratories, come from two specific facilities in India, and include simvastatin, metformin, pravastatin, amoxicillin, clarithromycin. A complete list of affected drugs is available on the FDA site.

The action is a proactive measure; as of press time, there was no evidence that people had been harmed from the drugs, and the drugs which are already in the U.S. don't appear to pose a risk, an FDA official said in a Sept. 16 Washington Post article. The agency has determined that its action won't lead to a drug shortage, except in the case of the antiviral ganciclovir, because Ranbaxy is its sole U.S. supplier. As such, the FDA won't detain shipments of this drug, but plans to enhance oversight of it.

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From ACP Internist

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On the blog: new diabetes device on the horizon

On the ACP Internist blog this week, we look at trials of a gastrointestinal liner for type 2 diabetes , the effectiveness of TV shows in providing health information, and as always, Medical News of the Obvious.

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Cartoon caption contest

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Vote for your favorite entry

ACP HospitalistWeekly's cartoon caption contest continues. ACP staff has selected three finalists for the latest contest and is now asking readers to vote for their favorite caption to determine the winner. In this contest, readers were asked to fill in the blanks "Mad Lib" style in this caption: It's ________. They're ________ about their __________.

Go online to view the cartoon and pick the winner, who receives a copy of "Medicine in Quotations," ACP's comprehensive collection of famous sayings relating to sickness and health, disease and treatment and a portrait of medicine throughout recorded history.

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ACP Hospitalist provides news and information for internists about the practice of medicine and reports on the policies, products and activities of ACP. All published material, which is covered by copyright, represents the views of the contributor and does not reflect the opinion of the American College of Physicians or any other institution unless clearly stated